Anaesthesia for Valvular Heart Disease

Moderated by
Dr. Chitra
Presented by
Mukesh kumar sah
Contents

 Definition  Common Complications

 Types of VHD  Laboratory Evaluation
 General Evaluation of  Special Studies
Patients  Pre-medication
 History Taking  Anti Coagulation Management
 New York Association –  Special Valvular Disorders
Functional Classification  Mitral Stenosis (MS)
of Heart Disease  Mitral Regurgitation (MR)
 Physical Examination  Mitral Valve Prolapse
Definition – Valvular Heart Disease (VHD)

An acquired or congenital disorder of

a cardiac valve characterized either
by
 Stenosis (obstruction) or
 Regurgitation (backward flow of
blood)
Common Types of Valvular Heart Diseases

 Mitral Stenosis  Mitral Valve Prolapse

 Mitral Regurgitation  Aortic Stenosis

 Tricuspid Stenosis  Idiopathic Hypertrophic

and Regurgitation Subaortic AS

 Pulmonary Stenosis  Aortic Regurgitation

and Regurgitation lkjadsflkjasdfk
 General Evaluation of Patients

 Key Considerations

 Severity of Lesion

 Its Hemodynamic significance

 Residual ventricular function

 Presence of secondary effects on Pulmonary,

Renal and Hepatic functions

 Concomitant Coronary Artery Disease (CAD)

 History Taking

 Key Considerations

 Age

 History of rheumatic fever, i/v drug abuse

 Symptoms related to ventricular function

 Exercise Tolerance
 Fatigueability
 Pedal edema
 Shortness of breath (dyspnoea), when lying flat (orthopnoea), or at night
(paroxysmal nocturnal dyspnoea)

 Chest pains and neurological symptoms as some valvular lesions

a/s with thromboembolic phenomenon
 History Taking

 Prior procedures such as valvotomy or valve replacement and

their effects

 Review of medications to evaluate efficacy and exclude

serious side effects. Commonly used agents
 Digoxin
 Diuretics
 Vasodilators
 ACE inhibitors
 Anti-arrhythmics
 Anticoagulants
 New York Heart Association - Functional
Classification of Heart Disease

 Useful for grading clinical severity of heart failure and

estimating prognosis

Description Grade

Asymptomatic except during severe exertion 1

Symptomatic with moderate activity 2

Symptomatic with minimal activity 3
Symptomatic at rest 4
 Physical Examination

 Abnormal Pulse with possible type of disorder

Pulse Abnormality Possible Disorder

Low Volumic Pulse Mitral Stenosis (MS)

Mitral Regurgitation (MR),

Water Hammer Pulse
Aortic Regurgitation (AR)

Slow Rising Pulse Aortic Stenosis (AS)

Irregular Rate and Rhythm Atrial Fibrillation (AF)

Physical Examination
 Search for signs of congestive heart failure

 Right sided

 Jugular Venous Distension

 Hepatospleenomegaly

 Pedal Edema

 Left sided

 S3 gallop

 Pulmonary rales

 Cardiomegaly

 Neurologial deficits secondary to embolic phenomenon to be seen

 Physical Examination

 Auscultatory findings – confirm the valvular dysfunction

S1 S2
Closure of mitral and Closure of aortic and
tricuspid valves pulmonic valves

Diastole Diastole

Systole

S1 S2
Common Complications

 Acute and Chronic Heart Failure

 Spontaneous Bacterial Endocarditis

 Arrhythmias - AF

 Thromboembolism-stroke, TIA

 Abnormal heart structure

 Laboratory evaluation

Hemogram Anemia

Blood Glucose Exclude DM

Lipid Profile Risk factor for IHD

S.electrolytes Low K+ f/o diuretics

Urine R/M, s.creatinine BUN Renal Function Tests

S.bilirubin, SGOT, SGPT LFT( Right Heart Failure)

Arterial Blood Gases In Patients with Pulmonary Symptoms

PT and aPTT Reversal of Anti Coagulants

Cardiac size
Chest X Ray
Pulmonary Vascular Congestion

Rhythm and Conduction Abnormalities

RVH/LVH
ECG ST-Segment Changes
Signs of digoxin toxicity (prolonged PR
interval and arrhythmias)
 Special Studies

 For Diagnosis and Prognosis

 Echocardiography

 Radionucleotide ongiography

 Cardial catheterization

 Following things should be analyzed

 Which valvular abnormality is most important hemodynamically?

 What is the severity of that lesion?

 Degree of ventricular impairment?

 Hemodynamic significance of other identified abnormalities

 Any evidence of CAD

 Pre-medication

 Patients with Normal Ventricular Functions

 Standard doses of any of used agents

 Patients with Poor Ventricular Functions

 Doses to be reduced in proportion to severity of ventricular

impairment

 Supplemental O2

 Pulmonary Hypertension
 Pre-medication

 Antibiotic Prophylaxis
 The risk of infective endocarditis in patients with Valvular Heart Disease following bacteremic
events including dental, oropharyngeal or nasopharyngeal, gastrointestinal or genitourinary
surgery any I & D is well established
 Prophylaxis should follow general guidelines recommended by the American heart association
 For Dental, Oral Respiratory Tract or Esophageal Procedures
 Standard General Prophylaxis
 Amoxicillin - Dosage: Adults - 2 gms, Children – 50 mg/kg; Mode: Orally 1 hr before
Procedure
 Inability to take Oral Medication
 Ampicillin – Dosage: Adults - 2 gms, Children – 50 mg/kg; Mode: i/m or i/v 30 mins before
procedure
 For Genitourinary or Gastrointestinal Procedures
 For High Risk Patients
 Ampicillin + Gentamycin ( Dosage: 1. 5 mg/kg, Mode i/m or i/v 30 mins before procedure), six
hours later Ampicillin (Dosage: Adults – 1 gm children 25 mg/kg, Mode: i/m or i/v ) or
Amoxicillin (Dosage: Adults 1 gm, Children 25 mg/kg, Mode: Orally)
 For High Risk Patients – Allergic to Ampicillin
 Vancomycin (Dosage: Adults – 1 gm, Children – 20 mg/kg) + Gentamycin ( adults & children
1.5 mg/kg, Mode: i/m or i/v, within 30 mins before starting procedure)
 Pre-medication

 Anticoagulation Management
 Patients receiving anticoagulants can have their drug regimen interrupted 1-3 days
preoperatively
 Warfarin stopped 3 days prior to Surgery and restart 2-3 days post operation
 If thromboembolic risk deemed high, stopped the day before surgery and reversed
with vit K or fresh frozen plasma, i/v heparin therapy then initiated 12-24 hrs post-op
once surgery hemostasis is adequate
 Incidence of thromboembolic complications increases with
 Prior history of embolism and the presence of thrombus
 Atrial fibrillation
 Prosthetic mechanical valve
 Caged ball mechanical prosthesis (starr – edwards) – highest (mitral or
tricuspid)
 Tilting disc valves ( ST Judes) – Intermediate
 Bioprosthesis ( porcine or bovine tissue valves) – lowest
Special Valvular Disorders – Mitral Stenosis

 Etiology
 Delayed complication of Rheumatic fever
 66% of patients are females
 Stenotic process begins after minimum period
of 2 years following acute disease and results
from progressive fusion and calcification of
value leaflets
 Symptoms develop after 20 – 30 years when
orifice reduced to less than 2 cm2
Particulars Dimensions

Normal Aperture 4 – 6 cm2

Mildly Stenotic 1.5 – 2.5 cm2

Usually have symptoms when
areas reduced by 50% Moderately Stenotic 1.1 – 1.5 cm2

Severe Stenotic < 1 cm2

 Less than 50% patients – Isolated MS

 Remaining - Also have MR
 Upto 25% rheumatic involvement of AV (AS or AR)
 Pathophysiology

 Valve leaflets thicken, calcify

and become funnel shaped
(Fish Mouth Valve)

 Restriction of blood flow

through the Mitral value results
in a transvalvular pressure
gradient – That depends on CO,
HR (diastolic time) and
presence of normal Atrial kick
Pathophysiology

Increase in either HR or CO Higher flow across Valve

Supraventricular Higher Transvascular

LA Dilates
Tacchycardias (AF) Pressure Gradient

Elevation in Left Atrial Chronic Pulmonary

Pressure Vascular Changes
Blood Flow Statis

Transmitted to Irreversible Increase in

Formation of Pulmonary Capillaries Pul. Vascular Resistance
Thrombi Reduced Lung
Compliance
If PCP > 25 mmHg
Pulmonary Hypertension
Ch. Dyspnoea
Transudation of Capillary
Pulmonary Edema
Fluid Rt. Ventricular Failure

TR or PR Dilatation of RV
 Diagnosis

 Clinical manifestations
 Chronic dyspnoea

 Embolic events common in patients with MS and AF.

Dislodgement of clots from left atrium results in systemic
emboli – most commonly cerebral, pulmonary emboli,
pulmonary infarction, hemoptysis and recurrent bronchitis

 Chest pain occurs in 10-15% of patients - emboli in coronary

circulation or acute right ventricular pressure overload

 Hoarseness due to compression of left recurrent laryngeal

nerve by enlarged left atrium
 Diagnosis

 Physical findings
 On palpation
 Low volume pulse
 Tapping apex

 On auscultation
 Opening Snap heard in expiration medial to cardiac apex,
follows S2 by 0.05 to 0.12 sec
 OS followed by low pitched, rumbling, diastolic murmur
heard best at apex with pt. in left lateral recumbent position
Opening snap

S1 S2
Diagnosis

 Laboratory Evaluation
 Chest X Ray
 Straightening of left border of heart

 Prominence of main pulmonary artery

 Dilatation of upper lobe pulmonary veins

 Backward displacement of esophagus by enlarged lt.

atrium
 Kerly B lines in lower and mid lung fields

 ECG
 Right axis deviation and RVH

 Tall and peaked P wave

 Echo - most sensitive and specific

 Treatment

 Medical management is primarily supportive

 Limitation of physical activity
 Anticoagulation ( with history of emboli, AF, old age)
 Na+ restriction
 Diuretics
 Digoxin – only in patients with AF and a rapid ventricular response
 Beta blockers to control Heart Rate
 Valve replacement
 Valvuloplasty or Percutaneous transeptal ballon valvuloplasty
 Valve replacement surgery – recurrent MS following valvuloplasty
 Anaesthetic Management
 Objectives
 Heart Rate - Keep slow to allow for diastolic filling. Avoid sinus
tacchycardia
 Rhythm – Sinus rhythm
 Preload – maintain or slightly increase to help with ventricular filling
 Afterload – SVR should be maintained, avoid decreases in SVR, avoid
increase in PVR
 Contractility – maintain to provide adequate CO
 Monitoring
 Direct intraarterial pressure
 ECG-notched p wave
 Pulmonary artery Pressure-prominent a wave and decreased y decent
Anaesthetic Management

 Choice of agents

 Regional Anaesthesia
 Epidural is preferred over spinal due to gradual onset of
sympathetic block with epidural
 General anaesthesia
 Ketamine – poor induction agent for GA because of sympathetic
stimulation
 Pancuronium induced tachycardia to be avoided

 Volatile agents – produce undesirable vasodilatation or precipitate

junctional rhythm with loss of an effective Atrial kick
 Halothane – most suitable because it reduces Heart Rate and is least
vasodilating
 NO2 – avoided as causes increase in PVR
Anaesthetic management

 Intra-op tacchycardia

 Deepening anaesthesia with opioid or b-blockers

(esmolol, proponalol)

 In case of AF

 control rate with diltiazem or digoxin

 Sudden supraventricular tachycardia - cardioversion

 As vasopressor - phenylephrine preferred over ephedrine as

former lacks b-agonist activity

 Acute hypertension or afterload reduction done under

hemodynamic monitoring
 Mitral Regurgitation

 A portion of LV volume is ejected back into

LA during systole because of an incompetent
valve
 Etiology
 Acute
 Myocardial ischemia / infarction (
papillary muscle dysfunction or rupture
of a chorda tendenae)
 Infective endocarditis
 Chest trauma
 Chronic
 Rheumatic fever
 Congenital or developmental
abnormality of valve
 Dilatation, destruction or calcification
of mitral annulus
 Pathophysiology

 Reduction in forward SV due to backward flow of blood into left

atrium during systole ( can be as much as 50% of SV)

 Left ventricle compensates by dilating and increasing end diastolic

volume

 Regurgitation reduces left ventricular afterload but which may

enhance contractility

 End systolic volume remains normal but eventually increases as

disease progresses

 With time, patients with Chronic MR develop eccentric left ventricular

hypertrophy and progressive impairment in contractility
 Volume overload of LA
Volume overload of LV
LA dilation
Early Normal LA Late
LV filling Fiber size pressures Contractility
Stroke volume BP and CO
Cardiac output and BP
Reflexive arteriolar
maintained
constriction
SVR

Regurgitation

LA pressure Pulmonary
Mitral regurgitation congestion
 Pathophysiology

 The regurgitant volume passing

through the mitral valve is
dependant on the
 Size of the mitral valve orifice

 Heart rate (systolic time)

 Lt. ventricular – lt. atrial

pressure gradient during
systole
 Systemic vascular
resistance
 Lt. atrial compliance
 Diagnosis

 Clinical manifestations
 Depend on degree of atrial compliance
 Normal or reduced compliance (acute MR) –
pulmonary venous congestion and edema,
signs of right sided heart failure
 Increased compliance (chronic MR) – signs of
decreased cardiac output
 Most patients exhibit features of both
 Diagnosis

 Physical Findings
 Hyperdynamic Apex

 On auscultation
 Wide splitting of S2 ( pre mature closure of
aortic valve)
 Blowing pan systolic murmur best heard at the
apex and often radiating to left axilla

S1 S2
 Diagnosis

 Laboratory Evaluation

 Chest X – Ray
 Left Atrial Enlargement
 Pulmonary Venous Congestion
 Kerly B Lines

 ECG
 Left Atrial Enlargement may be present

 ECHO
 To know the cause and degree of left ventricular function
 Treatment

 Medical Treatment

 Digoxin, Diuretic and Vasodilators

 Surgical Valvuoplasty

 Usually reserved for those with symptomatic MR

moderate(Regurgitant Volume – 30 to 60% S V)

severe (Regurgitant Volume – more than 60% S V)
 Anaesthetic Management
 Objectives
 Heart Rate – avoid slow heart rate (ideally 80 to 100 beats per minute),
faster rate decreases regurgitant volume
 Rhythm – maintain sinus rhythm
 Preload - Excess fluid will dilate the left ventricle and worsen
regurgitation. Need adequate volume to maintain forward stroke
volume. Pre load reduce with Vasodilators and diuretics
 Afterload – Decreases are beneficial
 Contractility – minimize drug induced myocardial depression
 Monitoring
 Pulmonary Artery Pressure
 Intraarterial pressure
 ECG
 Color flow Doppler TEE
Anaesthetic Management
Choice of agents
 Patients with well preserved ventricular function tend to do well with most
anaesthetic techniques
 Regional Anaesthesia
 Spinal and epidural are well tolerated (avoid bradycardia)

 General Anaesthesia
 Patients with moderate to severe Ventricular impairment are very sensitive to depressant
effects of volatile agents
 Opioid based anesthesia more suitable for them
 Pancuronium is beneficial
 Contractility-hypotension managed by manipulating HR and volume.severe hemodynamic
instability treated with dobutamine and low dose epinephrine
 Afterload reduction done by increasing anesthetic depth,vasodilator and inodilator.small
dose ephedrine
 Hypoxia,hypercapnia,acidosis should be tested and corrected
 Mitral Valve Prolapse (MVP)

 Also known as Systolic Click Murmur Syndrome, Barlow’s

Syndrome, Sloppy Valve Syndrome or Billowing Mitral Leaflet
Syndrome
 Relatively common abnormality - present in 5% of general
population ( 15% of women)

 Etiology
 Sporadic
 Familial
 Connective tissue disorder
 Marsan Syndrome
 Esler Danlos Syndrome
 Osteogenesis Imperfecta
Mitral Valve Prolapse (MVP)

 Pathology
 myxomatous degeneration of valve leaflets. Mitral annulus may
be dilated.
 Posterior mitral leaflet most commonly affected
 MVP causes stress on papilary muscles  Dysfunction and
Ischemia of papilary Muscles  More stress on diseased mitral
valve
 Often associated with MR
 Prolapse accentuated by maneuvers that decrease ventricular
volume (preload) like standing ,Valsalva
 Prolapse diminished by maneuvers that increase ventricular
volume (preload) like squatting and isometric exercises
Mitral Valve Prolapse - Diagnosis

 Clinical Manifestations - Majority of patients are

asymptomatic. In small percentage  progressive myxomatosis
degeneration
 Arrthymias (psVT, VT) – Palpitation, Light Headedness,
Syncope
 Chest pain
 Embolic events (TIA)
 Infective endocorditis
 Florid MR
 Sudden death
Mitral Valve Prolapse - Diagnosis

 Physical Findings
 On Auscultation
 Mid or late systolic click 0.14 seconds after S1 with or without a
late apical systolic murmur

 Laboratory Evaluation
 Chest X Ray
 ECG – usually normal or inverted or biphasic T waves or ST segment
changes inferiorly
 Paroxymal supra ventricular tachycardia common
 Echo – systolic prolapse of mitral valve leaflets in to left atrium.
Anaesthetic Treatment

 based on their clinical course

 Most patients are asymptomatic and need only a/b prophylaxis
 Patients with systolic murmur – at risk for infective endocarditis
 Ventricular arrthymia may occur in intra-op / respond to
lidocaine or beta blockers
 Relatively deep anaesthesia with a volatile agent usually
decreases incidence of intraop arrthymia
 Hypovolemia and factors that increase ventricular emptying 
increased sympathetic tone or decreased afterload – should be
avoided
 Phenylephrine preferred over ephedrine if there is need of
vasopressors
Thank You!